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2 Blue Cross and Blue Shield quality coverage that combines with a tax-deductible, tax-free health savings account: That s Health Check HSA Health Check HSA from Blue Cross and Blue Shield of Oklahoma is a health coverage plan Oklahomans can buy individually without belonging to an employer group. The plan also is intended to meet federal guidelines for use with a federally qualified health savings account (HSA). So, with Health Check HSA, you have a health insurance plan that allows you to open a health savings account with a qualified financial institution and benefit from the money-saving tax advantages the account provides. With Health Check HSA, your membership belongs to you, not an employer. Even if you change jobs, you don t have to give up your health care benefits. How does Health Check HSA work? With Health Check HSA, you can purchase a health insurance plan and make tax-deductible deposits in a health savings account. Health Insurance Premiums This money pays for affordable health insurance to cover major medical expenses. With Health Check HSA, there are many annual deductible options for you to choose from for both single and family coverage. Tax Deductible Savings When you deposit funds into a federally qualified health savings account, you can receive tax deductions, and may earn interest that is tax free. Funds you withdraw are tax-free as long as they are used to cover qualified health care costs. Health Check HSA High-deductible insurance Protects you from large medical bills Tax-free savings to cover out-of pocket medical care expenses My mom is self employed. She chose Health Check HSA. It s the right plan for us. Health Savings Account } Deposits can be tax deductible and roll over each year Helps pay your deductible and coinsurance Helps pay for other services not covered under your health plan: vision, dental, etc. 2

3 Examples of how to use Health Check HSA: While playing basketball, John fell and broke his leg. He was taken to the emergency room for treatment. He has no other charges this year that have been applied toward his $1,500 annual deductible for single coverage. John has Health Check HSA his tax-deductible savings will cover the charges for the services he received at the hospital. (His health insurance would not provide benefits until he reached his deductible.) Mary has Health Check HSA family coverage, and the family has met its $6,000 deductible. Mary s daughter Amy catches strep throat at school and needs to go to the doctor. Because the family has met the annual deductible, and Amy visited a BlueChoice PPO doctor, their health insurance will pay 80 percent of the office visit charge. Mary elects to use her tax-free health savings account to pay for the remaining 20 percent of Amy s care. Ron is in good health and about to turn 65. He has rolled over a large amount of money (more than his annual deductible) in his tax-free health savings account. After he turns 65, the HSA becomes similar to an Individual Retirement Account (IRA). Ron is free to use some of his HSA savings for living expenses, but must pay normal income tax on what he withdraws for non-medical payments. Ron will keep as much money as he wishes in the health savings account for future medical payments (tax-free). Who is covered? Applicants choose the coverage that best meets their needs. More choices mean more flexibility. With Health Check HSA, you can choose: Coverage for: just yourself your spouse you and your spouse you and your children your spouse and your children or your entire family. Lower rates for women who don t need maternity benefits. Preferred non-tobacco-user s rates if you have not smoked or used tobacco products in the past 12 months. What is covered? Among the health care services covered are: Preventive care benefit up to $300/year Emergency accident and medical care Outpatient surgery Semi-private hospital room All necessary hospital services, including operating and delivery rooms, drugs, whole blood, anesthesia and oxygen Intensive care unit Physician s surgical and medical services, both inpatient and outpatient Diagnostic services, including radiology, CAT scan and EKG Therapy services, including physical and occupational, dialysis, chemotherapy and radiation Ambulance services Maternity services (if you purchase coverage with maternity benefits; benefits are available after maternity coverage has been in effect for 365 days or more) Routine newborn nursery care Allergy testing and allergy injections Routine children s physical examinations for covered children through age 18 Childhood immunizations for covered children through age 18 Annual gynecological exams and Pap smears Discounts on supplemental health care products and services, including vision and hearing, and even on merchandise such as bicycle helmets and household child-safety products. Prostate cancer screening Hospice services Durable medical equipment Rehabilitation care Prosthetic appliances Orthotic devices 3

4 Choose the annual deductible that best fits your needs and budget. The deductible is the amount the insured person or the insured family as a whole pays for covered services, per calendar year, before Blue Cross and Blue Shield begins paying a percentage of the health care charges. Funds from your health savings account can be used to pay charges up to your deductible, or to pay the percentages of health care charges your insurance plan doesn t pay. Whether or not you use your health savings account funds or how often you use them is entirely up to you Some people prefer a lower annual deductible and a higher monthly premium, while others prefer a higher annual deductible and a lower monthly premium. Health Check HSA helps me make the most of my health coverage benefits. Option 1 (single) Option 2 (single) Option 3 (single) Option 4 (single) Option 5 (single) Option 6 (single) Option 7 (family) Deductible* $1,500 $1,500 $2,000 $2,500 Coinsurance** 100% Out-of-Pocket Max*** $6,000 Maximum Annual Deposit to HSA $1,500 $1,500 $2,000 $2,500 $2,700 $2,700 Option 8 (family) $10,000 Option 9 (family) $4,000 $6,000 $4,000 Option 10 (family) $6,000 Option 11 (family) $6,000 $10,000 $5,450 Option 12 (family) $10, % $10,000 $5,450 There is a federally mandated maximum amount that you can allocate to your health savings account per year. That amount depends on the health insurance deductible option you choose. Remember, the money you don t use by the end of the calendar year rolls over to the next year and can earn interest. It s not a use it or lose it account and it s tax-free. With Health Check HSA, your dollar can pay for more. Affordable rates and easy payments Because it s from Blue Cross and Blue Shield of Oklahoma, you know Health Check HSA is a quality health insurance plan. It s also affordable: Blue Cross and Blue Shield of Oklahoma combines checking account holders at participating Oklahoma banks, credit unions and savings and loans pooling them together and providing individuals and families with group benefits at competitive, group-type rates. To benefit from Health Check HSA rates, you simply authorize your participating Oklahoma bank, credit union or savings and loan to deduct your health insurance premium automatically from your personal checking account. That s an added convenience, as you re saved the hassle of paying bills deductions are made at the same time each month. 4

5 More physician and hospital choices Blue Cross and Blue Shield s Blue Choice PPO network includes doctors, hospitals and other health care professionals throughout Oklahoma. Choosing from among the thousands of health care providers who participate in the network will help you make the most of your health coverage benefits. (See page 7 for details on how you can save with the Blue Choice PPO network.) Blue Cross and Blue Shield network doctors and hospitals will: File your claims for you and receive payment for your covered services directly from Blue Cross and Blue Shield of Oklahoma. You don t have to worry about filing claims or turning over payments to your doctor. Accept Blue Cross and Blue Shield of Oklahoma s maximum allowed amount for your covered services as payment in full, less your deductible and coinsurance amounts where applicable. Take care of required pre-certifications for you if you need to be hospitalized. Blue Card benefits nationwide With the Blue Card program, members can receive their Blue Cross and Blue Shield of Oklahoma benefits while traveling out-of-state. Through Blue Card, Blue Cross and Blue Shield of Oklahoma members receive in-network benefits from doctors and other health care providers in all 50 states. When you see the Blue Card PPO-in-a-suitcase on your I.D. card, you know your benefits travel with you. Prescription drug coverage In addition to doctors and hospitals, Blue Cross and Blue Shield networks also include pharmacies. Choosing a network pharmacy will help you obtain your maximum prescription drug benefits. When you show your I.D. card at a participating pharmacy, you ll receive discounts and your prescription drug claims will be filed for you. Blue Cross and Blue Shield of Oklahoma will process your claims and send any benefit payment due directly to you. (See page 7 for details.) Keep the flexibility you need. You can receive some benefits even if you don t use a Blue Choice PPO network doctor. That s another Blue Cross and Blue Shield advantage: You have the flexibility to choose the hospitals and doctors you feel most comfortable with without giving up your benefits entirely. However, you receive your best benefits when you choose Blue Cross and Blue Shield network doctors and hospitals. And you receive a higher level of benefits for choosing Blue Choice PPO network doctors and hospitals. (See page 7 for more details.) 5

6 Blue Cross and Blue Shield of Oklahoma helped me get the coverage I needed for my family so I can have the tax advantages of my own health savings account. Term life coverage and accidental death and dismemberment coverage are included* Each person who has Blue Cross and Blue Shield individual health coverage receives of term life insurance and of accidental death and dismemberment insurance through Blue Cross and Blue Shield of Oklahoma s life insurance affiliate. *Rates quoted include premium for term life and accidental death and dismemberment insurance. Lifetime maximum $5 million per person, including $25,000 limit for psychiatric care.* * $25,000 limit does not apply to certain Severe Mental Illnesses, which are treated as any other physical disease or disorder. Coverage provisions Health Check HSA is age rated. Your rate is adjusted at the first of the month in which you enter a new age category. Age rating assures that premiums are fair for all subscribers. Rates are based on the claims experience of the subscriber group as a whole. You won t be singled out for a rate increase or cancelled because of high benefit utilization. Rates are calculated on a group basis, not individually. Benefits are subject to pre-existing condition limitations. No benefits will be provided for pre-existing conditions for a period of 12 months after coverage becomes effective. This provision applies to any condition or any charges relating to a condition existing during the 12 months immediately before the effective date of coverage. To apply, you must submit suitable evidence of insurability by answering the health questions on the enclosed application. If additional medical information is required, Blue Cross and Blue Shield of Oklahoma will contact you. Health savings account provisions If your application for Health Check HSA health coverage is accepted and your plan is in force, you can establish a health savings account. You can do this through Blue Cross and Blue Shield of Oklahoma s recommended trustee HSA Bank, or through any other administrator or financial institution that offers health savings accounts. Choose quality coverage and seize the new tax advantages. Apply today. Everyone needs health insurance. And with Health Check HSA, Oklahomans have a new way to combat rising health care costs: a quality, affordable, highdeductible health coverage plan and a tax-free health savings account to cover qualified health care expenses incurred before you meet the annual deductible. It s another innovative choice from Blue Cross and Blue Shield of Oklahoma. 6

7 Benefits Choose the plan that works best for your health care needs and budget. Annual deductible options There are many deductible options for both single and family coverage. (See page 4 for complete listing of deductible options.) In compliance with federal HSA health plan guidelines, family deductibles are calculated on an aggregate basis. Health care provider networks and coinsurance amounts Blue Choice PPO network: After you meet your annual deductible, most covered services are paid at 80 percent. On options 6 and 12, most covered services are paid at 100 percent after you meet the annual deductible. Blue Traditional network: After you meet your annual deductible, most covered services are paid at 60 percent of the Blue Choice PPO allowance. You are responsible for any difference between the Blue Traditional and Blue Choice PPO maximum allowable amounts. Out-of network: After you meet your annual deductible, most covered services are paid at 60 percent of the Blue Choice PPO allowance. You are responsible for any difference between the out-of-network health care provider s charges and the Blue Choice PPO maximum allowable amount. For the most up-to-date listing of Blue Cross and Blue Shield of Oklahoma network doctors, hospitals and other health care providers, go to the Blue Cross and Blue Shield of Oklahoma Web site at and click Locate a Health Care Provider. Preventive care benefit $300 per year Prescription drug coverage After you meet your annual deductible, benefits are paid at 70 percent of allowable charges; 100 percent of allowable charges on options 6 and 12. Annual out-of-pocket maximum (includes deductible) There are many out-of-pocket maximum options for both single and family coverage. (See page 4 for complete listing of out-of-pocket maximum options.) Mental health benefits After you meet your annual deductible, covered services are paid at 50 percent; 100 percent on options 6 and 12. The $25,000 lifetime limit on inpatient and outpatient services does not apply to certain severe mental illnesses, which are treated as any other physical disease or disorder. (There is a $1,000 calendar-year limit on outpatient mental health services.) 7

8 This is not a contract. The product description in this brochure is not intended to be more than a summary of the benefits available to you through the program. This brochure does not contain a complete listing of the exclusions, limitations and conditions that apply to the benefits shown, nor does it contain additional benefits that are available to you. Full information can be found, including medical necessity and pre-existing condition provisions, in the specific product s contract or member s certificate of benefits booklet. Health savings accounts are subject to rules set out in the Internal Revenue Code and IRS regulations, which may change or be interpreted. BCBSOK is offering a health plan only, and is not offering tax or investment advice. The information in this brochure is a summary, and you should seek advice from qualified tax and investment advisors for details regarding your HSA and the tax treatment of that arrangement. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks Blue Cross and Blue Shield Association 2005, Blue Cross and Blue Shield of Oklahoma (11/05)

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